Nokea
The home health nurse is caring for the client newly diagnosed with multiple sclerosis. Which client issue is of most importance?
- A. The client refuses to have a gastrostomy feeding.
- B. The client wants to discuss if she should tell her fiancé.
- C. The client tells the nurse life is not worth living anymore.
- D. The client needs the flu and pneumonia vaccines.
Correct Answer: C
Rationale: Suicidal ideation indicates a mental health crisis, requiring immediate intervention. Gastrostomy refusal, disclosure to fiancé, and vaccines are less urgent.
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The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two (2) times in the month. Which question is most important for the nurse to ask the client?
- A. Have you experienced any difficulty with your menstrual cycle?
- B. Have you noticed a rash across the bridge of your nose?
- C. Do you get tired easily and sometimes have problems swallowing?
- D. Are you taking birth control pills to prevent conception?
Correct Answer: C
Rationale: Fatigue and dysphagia are MS symptoms, and their presence supports the diagnosis. Menstrual issues, rashes (SLE-related), and birth control are less relevant to MS.
Which surgical procedure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the signs/symptoms of the disease process?
- A. There is no surgical option.
- B. A transsphenoidal hypophysectomy.
- C. A thymectomy.
- D. An adrenalectomy.
Correct Answer: C
Rationale: Thymectomy can reduce symptoms in myasthenia gravis by removing the thymus, often implicated in autoimmunity. Other surgeries are irrelevant.
The nurse is assessing a client with cutaneous lupus erythematosus. Which intervention should be implemented?
- A. Use astringent lotion on the face and skin.
- B. Inspect the skin weekly for open areas or rashes.
- C. Dry the skin thoroughly by patting.
- D. Apply anti-itch medication between the toes.
Correct Answer: C
Rationale: Patting the skin dry prevents irritation in cutaneous lupus. Astringents worsen dryness, weekly inspections are too infrequent, and toe medication is irrelevant.
The nurse caring for a client diagnosed with Multi Organ Dysfunction Syndrome (MODS) is preparing to administer morning medications. Which medication would the nurse question?
- A. Cefazolin sodium IVPB every six (6) hours.
- B. Furosemide by mouth twice daily.
- C. Metoprolol IVP every four (4) hours and prn.
- D. Acetaminophen by mouth every four (4) hours prn.
Correct Answer: C
Rationale: Metoprolol IVP every 4 hours in MODS risks hypotension in cardiovascular dysfunction. Cefazolin, furosemide, and acetaminophen are appropriate.
The nurse caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first?
- A. Flush the skin with water and try to get the area to bleed.
- B. Notify the charge nurse and complete an incident report.
- C. Report to the employee health nurse for prophylactic medication.
- D. Follow up with the infection control nurse to have laboratory work done.
Correct Answer: A
Rationale: Flushing and inducing bleeding at the site immediately reduces viral load. Notification, prophylaxis, and lab work follow.